Gluten Free Works: TREATMENT GUIDE Get well and stay healthy living gluten free
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What Are Elevated Liver Enzymes?
Hypertransaminasemia is a chronic condition of elevated blood liver transaminase enzymes, commonly called “liver enzymes,” that signifies hepatocellular (liver) injury.
Q: What are serum transaminases?
A: Transaminases are the liver enzymes ALT and AST. ALT is the abbreviation for alanine aminotransferase enzyme and AST is the abbreviation for aspartate aminotransferase enzyme.
Transaminases are commonly measured in routine blood tests to determine liver function. Elevated ALT and AST transaminases indicate inflammation of the liver. Other specific tests must follow to determine the cause of inflammation.
What Is Hypertransaminasemia In Celiac Disease and/or Gluten Sensitivity?
- Relationship between hypertransaminasemia and celiac disease. Hypertransaminasemia is a frequent atypical feature of untreated celiac disease and may present celiac disease to the physician who ordered the lab study of liver enzymes.
- Relationship between hypertransaminasemia and intestinal permeability. Elevated liver enzymes indicate hepatocellular injury and correlate with intestinal permeability in celiac disease.1,2
- Relationship between hypertransaminasemia and type of celiac disease. In children, elevated transaminase levels were more significantly frequent in the classical type than atypical type of celiac disease.3
- Relationship between hypertransaminasemia and unknown origin. Underlying celiac disease should be considered in cases of persistently elevated liver function tests of unknown origin.2
- Relationship between hypertransaminasemia and gluten free diet. Asymptomatic celiac disease was found in six children in whom long-standing hypertransaminasemia of unknown cause led to an initial diagnosis of chronic or protracted cryptogenic hepatitis. Administration of a gluten-free diet caused a prompt improvement of both hepatic and intestinal biochemical/histologic abnormalities.4
How Prevalent Is Hypertransaminasemia In Celiac Disease and/or Gluten Sensitivity?
Hypertransaminasemia occurs frequently in untreated celiac patients. Aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) were found increased in 40% of patients prior to initiation of gluten free diet.5
Elevated transaminase levels (24.7%) was one of the most common laboratory findings in a study of children at diagnosis of celiac disease, and elevated transaminase levels were more significantly frequent in the classical type than atypical type of celiac disease.3
What Are The Symptoms Of Hypertransaminasemia?
- Hypertransaminasemia is marked by liver inflammation.
How Does Hypertransaminasemia In Celiac Disease and/or Gluten Sensitivity Develop?
- Elevated liver enzymes result from gluten exposure in celiac disease.
Does Hypertransaminasemia Respond To Gluten-Free Diet?
Yes. Celiac disease-related ALT and AST normalize in most celiac disease patients within one year on a gluten free diet.5
6 Steps To Improve Elevated Liver Enzymes In Celiac Disease and/or Gluten Sensitivity:
- 1Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:
- Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
- A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
- Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.
Correct Your Individual Nutritional Needs.
- Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
- Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.
Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the absorbing cells that make up the surface lining of your small intestine are better able to function.
- Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
- Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.6
- The intestinal lining may take up to a year to heal.
- 2 Reduce Inflammation. Foods to Eat and Foods Not to Eat:
Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).
- Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.7
- Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
- Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.7
- Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.7.
- Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.7
- Refined Sugars. Includes white sugar, corn fructose and high fructose corn syrup.
- Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.7
- Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.7
- Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
- Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
- High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
- Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
- Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
- Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
- Prebiotics/ High Fiber Foods. Food with fiber keeps our population of colonic microbes healthy.
- Protective Herbs and Spices. See below #6 below for examples.
- 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:
- 4 Manage Your Medications Safely:
Certain medications cause elevated liver enzymes and many cause liver damage. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.
This is not a complete listing.
- Acetaminophen (Tylenol) is a pain reliever that in high or prolonged doses causes liver damage.
- Flavocoxid (Limbrel) to treat osteoarthritis causes liver injury.
- Cholesteral drugs (Lipitor®, Zocor®, and others).
- Allopurinol (Zyloprim) for gout.
- Amiodarone for heart arrythmias.
- Baclofen (Lioresal) for spasms.
- Bupropion (Wellbutrin) for depression.
- Isoniazid for tuberculosis.
- Ketoconazole for funfal infections.
- Lisinopril (Zestril) for high blood pressure.
- Nonsteroidal anti-inflammatory drugs for pain.
- Omeprazole (Prilosec) for heartburn and gastrointestinal reflux disease.
- Risperidone (Risperdal) for schizophrenia and symptoms of bipolar disorder.
- Selective serotonin reuptake inhibitors for depression.
- Tetracyclines for infections.
- Valproic acid (Depakene) for seizures.
- Herbal preparations containing kava kava and germander.
- 5Nutritional Supplements To Help Correct Deficiencies:
The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.
- 100% Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.
- 6Manage Natural Remedies:
- Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
- If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
- Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
- What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.
Carminative Food Remedies:
- Raspberry.
- Carrot is also a cleansing digestive tonic.
- Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
- Redbeets also stimulate and improve digestion and are easily digested.
- Cabbage also stimulates and improves digestion and is also a liver decongestant.
- Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
- Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.
Carminative Herb Remedies:
- Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa. Drink as tea or use in cooking.
- Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
- Parsley also relieves indigestion.
- Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
- Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.
Carminative Spice Remedies:
- Cloves are also antispasmodic.
- Nutmeg is also useful for indigestion.
- Ginger.
Exercise improves circulation and rids the body of toxins.
- Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
- Weight training builds muscle. Read more about Exercise and Fitness.
- Stretching improves flexibilty. Read more about Exercise and Fitness.
Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal.
What Do Medical Research Studies Tell About Hypertransaminasemia In Celiac Disease and/or Gluten Sensitivity?
RESEARCH STUDY SUMMARIES
“Celiac Disease: Presentation of 109 Children.” This retrospective study investigating clinical and laboratory features of 109 patients with celiac disease to determine presentation and manifestations found that elevated transaminase levels were more significantly frequent in the classical type than atypical type.
Of 109 patients with celiac disease, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 ± 4.63 years and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings.
Iron deficiency anemia (81.6%), zinc deficiency (64.1%), prolonged prothrombin time (35.8%), and elevated transaminase levels (24.7%) were the most common laboratory findings. Eight percent of patients had at least 1 autoantibody, and 28 of 52 patients had low BMD. Four of 38 patients had abnormality in electroencephalograms. The prevalance of selective immunoglobulin (Ig) A deficiency was 9.1%. Histocompatibility antigen HLA-DQ and/or DQ8 genotypes were found in 91% of patients. Abdominal distention, iron deficiency, prolonged prothrombin time, hypoalbuminemia, and elevated transaminase levels were more significantly frequent in the classical type than atypical type.3
“Prevalence and clinical importance of hypertransaminasaemia in coeliac disease.” This study investigating the prevalence and potential pathogenetic factors of hypertransaminasemia in 178 patients with celiac disease prior to the initiation of a gluten free diet and assessment of the course of transaminases on a Gluten Free Diet, demonstrated that hypertransaminasemia before gluten free diet is frequent in celiac patients, correlates with intestinal permeability and normalizes on a gluten free diet in most patients.
Aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) were found increased in 40% of patients prior to initiation of gluten free diet. Of 5 selected study patients who underwent liver biopsy, mild to moderate hepatitis with septal fibrosis was found in 2 and minimal lymphocytic infiltrates of the portal tracts without inflammation of the bile ducts was found in 3. Underlying celiac disease should be considered in cases of persistently elevated liver function tests of unknown origin.5
“Elevated serum aminotransferase activity as an early manifestation of gluten-sensitive enteropathy.” In this case report, six children in whom long-standing hypertransaminasemia of unknown cause led to an initial diagnosis of chronic or protracted cryptogenic hepatitis were found to have asymptomatic celiac disease. Administration of a gluten-free diet caused a prompt improvement of both hepatic and intestinal biochemical/histologic abnormalities. Hepatic damage may be another “atypical” form of celiac disease in children.8
“Prevalence of hypertransaminasemia in adult celiac patients and effect of gluten-free diet.” This study investigating the prevalence of hypertransaminasemia and the effect of gluten-free diet (GFD) in 158 consecutive adult celiac patients, 127 women and 31 men, aged 18 to 68 years, found that in adult celiac patients elevated serum transaminases are a frequent finding and normalize in most cases after GFD. When they persist, liver biopsy is mandatory to further investigate hepatic involvement, which is our series was mainly attributable to chronic active hepatitis.
At diagnosis, 67 patients (42%) had raised aspartate and/or alanine transaminase levels (AST and ALT; mean, 47 IU/L, range, 30 to 190; and 61 IU/L, range, 25 to 470, respectively), whereas 91 patients had normal liver function tests (LFT). Patients with and without hypertransaminasemia were comparable for epidemiological data, body mass index (18.5 vs. 19.6), and severity of intestinal histological involvement. All patients were given a strict GFD and were followed for 1 to 10 years (median, 4). At 1 year, a highly significant improvement in intestinal histology was observed in both groups. In the 67 patients with raised transaminase levels body mass index (BMI) also increased significantly (from 18.5 to 21.0, P < .001), and transaminase levels normalized in 60 (95%). In the other seven cases liver biopsy showed fatty infiltration in two and chronic active hepatitis in the other five, related to chronic infection with hepatitis B virus in three and hepatitis C virus in one, and to autoimmune type in the fifth.9
CASE REPORT SUMMARIES
“Celiac disease manifested by polyneuropathy and swollen ankles.” This is a case study revealing celiac disease in a 27-year-old male who started to have his ankles swollen during his military service. He was examined at a military hospital where electromyoneurography showed the signs of distal sensory-motor polyneuropathy with axon demyelinization and weak myopathic changes, whereas histopathological examination of gastrocnemius muscle biopsy revealed some mild and nonspecific myopathy. Besides, he was found to have subcutaneous ankle tissue edemas and hypertransaminasemia. Due to these reasons, he was dismissed from the military service and examined at another hospital where bone osteodensitometry revealed low bone mineral density of the spine. However, his medical problems were not resolved and after the second discharge from hospital he was desperately seeing doctors from time to time.
Finally, at our institution he was shown to have celiac disease by positive serology (antitissue transglutaminase and antiendomysial antibodies) and small bowel mucosal histopathological examination, which showed total small bowel villous atrophy. Three months after the initiation of gluten-free diet, his ankle edema disappeared, electromyoneurographic signs of polyneuropathy improved and liver aminotransferases normalized. Good knowledge of celiac disease extraintestinal signs and serologic screening are essential for early celiac disease recognition and therapy.10
- Murray JA, The widening spectrum of celiac disease. American Journal of Clinical Nutrition. Mar 1999;69 (3):354-365. [↩]
- Novacek G, Miehsler W, Wrba F, Ferenci P, Penner E, Vogelsang H. Prevalence and clinical importance of hypertransaminasaemia in coeliac disease. Euopean Journal of Gastroenterology and Hepatology. Mar 1999;11(3):283-8. [↩] [↩]
- Kuloğlu Z, Kirsaçlioğlu CT, Kansu A, Ensari A, Girgin N. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩] [↩] [↩]
- Vajro P, Fontanella A, Mayer M, De Vincenzo A, Terracciano LM, D’Armiento M, Vecchione R. Elevated serum aminotransferase activity as an early manifestation of gluten-sensitive enteropathy. J Pediatr. 1993 Mar;122(3):416-9. [↩]
- Novacek G, Miehsler W, Wrba F, Ferenci P, Penner E, Vogelsang H. Prevalence and clinical importance of hypertransaminasaemia in coeliac disease. Euopean Journal of Gastroenterology and Hepatology. Mar 1999;11(3):283-8. [↩] [↩] [↩]
- Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
- Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
- Vajro P, Fontanella A, Mayer M, De Vincenzo A, Terracciano LM, D’Armiento M, Vecchione R. Elevated serum aminotransferase activity as an early manifestation of gluten-sensitive enteropathy. J Pediatr. 1993 Mar;122(3):416-9. [↩]
- Bardella MT, Fraquelli M, Quatrini M, Molteni N, Bianchi P, Conte D. Prevalence of hypertransaminasemia in adult celiac patients and effect of gluten-free diet. Hepatology. 1995 Sep;22(3):833-6. [↩]
- Djuric Z, Kamenov B, Katic V. Celiac disease manifested by polyneuropathy and swollen ankles. World J Gastroenterol. 2007 May 14;13(18):2636-8. [↩]
